External validation of the ovarian-adnexal reporting and data system (O-RADS) lexicon and the international ovarian tumor analysis 2-step strategy to stratify ovarian tumors into O-RADS risk groups.

IMPORTANCE: Correct diagnosis of ovarian cancer results in better prognosis. Adnexal lesions can be stratified into the Ovarian-Adnexal Reporting and Data System (O-RADS) risk of malignancy categories with either the O-RADS lexicon, proposed by the American College of Radiology, or the International Ovarian Tumor Analysis (IOTA) 2-step strategy. OBJECTIVE: To investigate the diagnostic performance of the O-RADS lexicon and the IOTA 2-step strategy. DESIGN, SETTING, AND PARTICIPANTS: Retrospective external diagnostic validation study based on interim data of IOTA5, a prospective international multicenter cohort study, in 36 oncology referral centers or other types of centers. A total of 8519 consecutive adult patients presenting with an adnexal mass between January 1, 2012, and March 1, 2015, and treated either with surgery or conservatively were included in this diagnostic study. Twenty-five patients were excluded for withdrawal of consent, 2777 were excluded from 19 centers that did not meet predefined data quality criteria, and 812 were excluded because they were already in follow-up at recruitment. The analysis included 4905 patients with a newly detected adnexal mass in 17 centers that met predefined data quality criteria. Data were analyzed from January 31 to March 1, 2022. EXPOSURES: Stratification into O-RADS categories (malignancy risk <1%, 1% to <10%, 10% to <50%, and ≥50%). For the IOTA 2-step strategy, the stratification is based on the individual risk of malignancy calculated with the IOTA 2-step strategy. MAIN OUTCOMES AND MEASURES: Observed prevalence of malignancy in each O-RADS risk category, as well as sensitivity and specificity. The reference standard was the status of the tumor at inclusion, determined by histology or clinical and ultrasonographic follow-up for 1 year. Multiple imputation was used for uncertain outcomes owing to inconclusive follow-up information. RESULTS: Median age of the 4905 patients was 48 years (IQR, 36-62 years). Data on race and ethnicity were not collected. A total of 3441 tumors (70%) were benign, 978 (20%) were malignant, and 486 (10%) had uncertain classification. Using the O-RADS lexicon resulted in 1.1% (24 of 2196) observed prevalence of malignancy in O-RADS 2, 4% (34 of 857) in O-RADS 3, 27% (246 of 904) in O-RADS 4, and 78% (732 of 939) in O-RADS 5; the corresponding results for the IOTA 2-step strategy were 0.9% (18 of 1984), 4% (58 of 1304), 30% (206 of 690), and 82% (756 of 927). At the 10% risk threshold (O-RADS 4-5), the O-RADS lexicon had 92% sensitivity (95% CI, 87%-96%) and 80% specificity (95% CI, 74%-85%), and the IOTA 2-step strategy had 91% sensitivity (95% CI, 84%-95%) and 85% specificity (95% CI, 80%-88%). CONCLUSIONS AND RELEVANCE: The findings of this external diagnostic validation study suggest that both the O-RADS lexicon and the IOTA 2-step strategy can be used to stratify patients into risk groups. However, the observed malignancy rate in O-RADS 2 was not clearly below 1%

What is the most relevant standard of success in assisted reproduction? Should BESST really be the primary endpoint for assisted reproduction?

A major problem in IVF procedures is a high rate of induced iatrogenic complications including multiple gestations. Until now, transfer of at least three embryos followed by the subsequent elective reduction of triplet or higher order gestations to twins, single embryo transfer (SET) with cryopreservation of the remaining embryos, as well as the application of SET in unstimulated cycles, serves to illustrate the diversity characterizing the worldwide effort of achievement of pregnancy that aims to avoid possible complications. The BESST (birth emphasizing a successful singleton at term) endpoint constitutes an interesting parameter imposing the safety of SET. However, the observed success rate (11.1%) requires elucidation of the specific pattern of endometrial behaviour around the implantation window as well as its involvement in the further support of gestation. Consequently, research has to focus primarily on the improvement of technical parameters to achieve an acceptable success rate during the IVF procedures as compared with spontaneous gestations

Leptin in pregnancy

Leptin is a 16-kDa polypeptide, encoded in humans by the LEP gene. This protein is probably involved in the regulation of ovarian function, oocyte maturation and embryo development, and in the implantation process. During pregnancy, leptin is produced in the placenta; its values increase in the maternal blood particularly in 7the second trimester and decline postpartum. Leptin levels may be abnormally high in pregnancies complicated by conditions such as diabetes mellitus and pre-eclampsia. The role of leptin in fetal physiology has not been clarified, although cord blood values correlate significantly with birth weight. It is expected that further research will provide new insight into the physiological importance of leptin in the pregnant woman and fetus

In vitro responsiveness of human post-menopausal myometrium to endothelin-1 and ovarian steroids

It has been shown in vitro that endothelin 1 (ET1) differentially affects the human myometrial contractility according to the hormonal profile of women. Our purpose was to test the hypothesis that ovarian steroids influence the ET1 induced myometrial contractility. We performed three types of experiments. Myometrial tissues were exposed to 17 beta-oestradiol (E), progesterone (P), E plus P (E+P) in concentrations 10-M-10, 10(-8)M, 10(-7)M, 10(-6)M and 10(-4)M (Type I), ET1 in concentrations 10(-10)M, 10(-9)M, 10(-8)M, 10(-7)M and 10(-6)M (Type II) and E+ET1, P+ET1 and E+P+ET1 in concentrations ranging from 10(-10)M to 10(-6)M (Type III). Tissue exposure to E, P and E+P did not significantly alter the pattern of spontaneous myometrial motility. ET1 (10-6M) induced a sustained long-lasting contraction, the initial part of which lasted 34 +/- 4min, elevating the initial baseline by 190 +/- 20%. This was followed by ripples of gradually increasing amplitude with no regular contractions up to the end of the period of observation (120 min). Addition of P or E+P to ET1 markedly restricted (p < 0.05) the elevation of initial baseline (P+ET1: 68 +/- 8%, P+E+ET1: 67 +/- 8%), and significantly shortened (p < 0.01) the duration of the alterations (P+ET1: 21 +/- 3 min, P+E+ET1: 26 +/- 3 min). These results demonstrate the lack of any significant effect of E and P or their combinations on the pattern of spontaneous myometrial motility in post-menopausal women. However, P alone or in combination with E exerted an inhibitory action on ET1-induced contractility on human post-menopausal myometrium. The physiological significance of these findings remains to be clarified. (C) 2005, Editrice Jurti

In vitro effects of endothelin-1 on the contractility of myometrium obtained from pre- and postmenopausal women

This study was conducted to evaluate the responsiveness of human nonpregnant myometrium to endothelin 1 (ET1) (10(-10) M-10(-6) M) and KCl (80 mM) in relation to the hormonal profile of the women, who were allocated into three groups: group 1, premenopausal follicular phase, n=14, group 2, premenopausal luteal phase, n=20, and group 3, postmenopausal women, n=12. At a concentration of 10(-6) M, ET1 in both groups 1 and 2 induced very low ripples of high frequency (group 1: 80 +/- 14%, n=5, group 2: 314 +/- 63%, n=11; P<0.05 compared with the pretreatment frequency) which lasted significantly longer in group 2 (29 +/- 2 min, n=10, P<0.05) than in group 1 (20 +/- 2 min, n=5), increasing the basal tone (group 1: 57.9 +/- 6%, n=5, group 2: 64.4 +/- 4%, n=6), the amplitude of myometrial contractility (group 1: 1.2 +/- 0.07 g, n=5, group 2: 1.6 +/- 0.1 g, n=7, P<0.05) and the area under the contractility curve (AUC; group 1: 8.4 +/- 1.1 g x min, n=6, group 2: 11.9 +/- 1.6 g x min, n=11). In group 3, ET1 (10-6 M) created a sustained long-lasting contraction (initial phase: 43 +/- 6 min, n=6) characterized by the complete obliteration of spontaneous contractility with no ripples at all, and increasing significantly (P<0.05) the amplitude of myometrial contractility (2.8 +/- 0.5 g, n=6), the AUC (24.7 +/- 3.3 g x min, n=6), as well as the basal tone (183.6 +/- 21%, n=6) compared with the two premenopausal groups. In all three groups KCl exposure induced an initial rise (mean amplitude value: 1 1 g) followed by a relaxation phase to the primal baseline level (mean duration value: 12 min). Addition of ET1 (10(-6) M) to KCl (80 mM) induced a similar pattern of contractility to that evoked by ET1 alone which, compared with KCl alone lasted significantly longer (P<0.05) in all three groups (group 1: 20 +/- 2 min, n=6; group 2: 23 +/- 2 min, n=6; group 3: 35 +/- 3 min, n=5). In group 3, the percentage change in basal tone was significantly smaller following KCl than after the combination of KCl plus ET1 (149 +/- 16%, n=5; P<0.01), indicating a different mechanism of contractility between KCl and ET1. These results demonstrate for the first time differences in myometrial response to ET1 between pre- and postmenopausal women. It is suggested that KCl and ET1 affect uterine contractility through different mechanisms and that ovarian steroids may play a regulatory role in human uterine responsiveness to ET1

Herlyn–Werner–Wunderlich syndrome: Report of a delayed diagnosed case with video presentation of the operative technique of vaginal septum resection

Herlyn–Werner–Wunderlich (HWW) syndrome is a rare congenital anomaly of Mullerian duct development characterized by uterus didelphys with blind hemivagina and ipsilateral renal agenesis. We present a case of a 29-year-old nulliparous woman, who was referred to our hospital complaining of chronic pelvic pain, dyspareunia, and a palpable mass in her vagina. At the age of 12, she underwent surgery because of a didelphys uterus diagnosis. Subsequently, she was operated on twice for endometriomas. At our institution, clinical and imaging findings revealed an obstructed hemivagina setting the diagnosis of HWW syndrome. Some of the various syndrome types may go unnoticed for months or even years after the onset of menstruation. Early diagnosis, followed by proper surgical treatment, is the key to avoid potentially severe complications. © 2021 Japan Society of Obstetrics and Gynecology

Total Laparoscopic Excision of an Altman Type IV Sacrococcygeal Teratoma with the Assistance of Intraoperative Transrectal Sonography

Objective: To present the case of a young patient with an Altman type IV sacrococcygeal teratoma (Fig 1) managed exclusively with laparoscopy. Design: A step-by-step demonstration of the technique. Setting: A 24-year-old patient complaining of dysmenorrhea, deep dyspareunia, chronic constipation, dyschezia, and bladder atony was diagnosed with a 5-cm cystic tumor compressing the low rectum and overlying the left levator ani muscle. Interventions: Laparoscopic excision of the tumor. At laparoscopy, significant bilateral pelvic venous congestion was found. The left medial and lateral pararectal fossa and the rectovaginal space were developed to the level of the pelvic floor. Several branches of the left internal artery and vein were dissected. The left hypogastric nerve and deep hypogastric plexus were dissected in an effort to preserve ipsilateral autonomic nerve supply to the rectum. Owing to the tumor&apos;s soft consistency and dense adherence to the surrounding structures, transrectal sonography facilitated dissection, which was performed medially to the mesorectal fascia and anteriorly to the presacral fascia. The middle sacral artery and peripheral branches of the internal iliac vasculature supplying the tumor were ligated. Part of the left levator ani had to be excised. The rectum was injured during the effort to detach the tumor from its lateral wall. The injury was repaired laparoscopically. The cut edge of the levator ani was used as a flap to reinforce the repair. Conclusion: Sacrococcygeal teratomas lying entirely in the pelvis (Altman type IV) are extremely rare [1,2]. Complete laparoscopic excision is challenging and potentially dangerous [3–5], but it is feasible with careful dissection. © 2020 AAG